Health inspection·April 29, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to provide adequate supervision when staff left Resident 1 unattended to prevent an avoidable accident from occurring for 1 of 3 sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a hip fracture (broken bone). Findings: During a review of Resident 1 ' s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility in December 2024 with multiple diagnoses which included Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident comprehensive assessment tool), dated 3/15/25, indicated, Resident 1 ' s decisions were poor and cues/supervision were required. The MDS further indicated, Resident 1 needed partial to moderate assistance while eating. During a review of Resident 1 ' s Fall Risk Assessment, dated 3/13/25, it indicated Resident 1 was at high risk for falls and Resident 1 had 3 or more falls in the past three months. During a review of Resident 1 ' s Care Guide, dated 3/20/25, indicated, Please do not leave me unattended .I may try to self transfer . During a review of Resident 1's nursing progress notes, it indicated Resident 1 had an unwitnessed fall on 4/12/25 and sustained a left hip fracture. Resident 1 was found down at 400 nurses station .CNA [Certified Nursing Assistant] set up dinner while resident was seated .patient found lying L lateral [left side] .ED [emergency department] was contacted for assistance . During a review of Resident 1 ' s x-ray results, dated 4/12/25, indicated Pelvic/hip pain following trauma .displaced (to move from its usual place) .fracture left hip. During a review of facility ' s reported incident (FRI) to the department, dated 4/17/25, the FRI indicated, . [Resident 1] underwent surgery for an intermedullary nailing [surgical procedure used to stabilize broken bones] on 4/13/25. The resident returned to our facility on 4/15/25 as a skilled resident where she is receiving physical [focus on restoring, maintaining and improving a person ' s ability to move and function] and occupational therapy [focus on improving a person ' s ability to Page 1 of 2 555698 555698 04/29/2025 Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150

F 0689 perform tasks, develop skills and maintain independence in their daily routine] to help her return to her prior level of functioning, and skilled nursing for pain management and surgical site care. Level of Harm - Actual harm Residents Affected - Few During an interview on 4/29/25 at 2:05 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated she left Resident 1 at the nurse ' s station to answer a call light. CNA 1 confirmed she did not let any staff know that Resident 1 was by herself. CNA 1 further confirmed all other staff were busy in other resident rooms. CNA 1 stated, Resident 1's fall could have been prevented if there was another pair of eyes on her. During an interview on 4/29/25 at 2:25 p.m., the Interim Director of Nursing (IDON) acknowledged that Resident 1 should be supervised during all meals and confirmed the CNA left Resident 1 unattended. IDON further acknowledged the fall could have been prevented if someone was watching Resident 1. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment/Fall Prevention dated 8/2024, the P&P indicated, It is the policy of this facility to .prepare a plan of care to reduce potential for future falls .If the Fall Risk Evaluation total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls .Prevention interventions will be initiated immediately . 555698 Page 2 of 2